An Interactive Allyship and Privilege Workshop for Trainees in Medicine

Introduction Despite growing efforts to increase diversity in recruitment and to teach principles of diversity, equity, and inclusion (DEI), representation of individuals underrepresented in medicine continues to fall short. This demonstrates a need for efforts that target the work environment and culture to increase retention alongside existing recruitment initiatives. We designed this interactive allyship workshop with a focus on building skills necessary for being an ally that has been missing in existing allyship curricula. Methods This workshop was led by multidepartmental faculty with experience in DEI training. Participants engaged in a number of interactive activities to reflect on their own identities and privilege and practiced ways to engage in difficult conversations. Prior to the workshop, participants completed a survey that was repeated at the workshop's completion to evaluate their perspective change and understanding of allyship. We also collected responses to a self-reflective exercise during the workshop. Results Participants included 68 anesthesia and surgery attendees, 53 of whom (78%) completed the postsurvey. Participants strongly agreed that this workshop was important to the workplace and medical training. Themes from the self-reflective exercises included endorsement of sponsorship and mentorship activities, community support, and advocacy. Discussion Interactive skill-building activities are important and effective at helping trainees develop as allies. Long-term follow-up is needed to assess longitudinal knowledge retention and translation into behavioral change to create a more inclusive and supportive work environment.


Introduction
Initiatives for advancing diversity, equity, and inclusion (DEI) have exploded in recent years, with the increase of diversity in recruitment at the forefront of academic medicine. 1While these efforts to advance diversity have yielded positive outcomes, gains in diversity have not been equitable across all groups, and much work remains in terms of addressing equity, inclusivity, and justice. 2 For example, in 2022-2023, women made up 57% of medical school matriculants. 3However, the percentages of Black (10%) and Hispanic (12%) matriculants were still far from their census in the general population, which, according to the 2021 Census, was 13.6% Black or African American and 18.9% Hispanic or Latino. 3,4Beyond matriculation, issues remain in the retention of trainees who identify as underrepresented in medicine (UIM) across the continuum of medical training. 5,67][8] The reasoning behind these trends is multifactorial-UIM trainees encounter obstacles ranging from navigating microaggressions and bias to being tasked as racial and ethnic ambassadors to social isolation. 9,10[12] Diversity in medicine also impacts health equity.Disparities in access to care remain an insurmountable hurdle in the care of underserved communities. 5Studies have shown that UIM students and non-White physicians have a greater predilection towards working in underserved communities and that patients are more likely to seek racially concordant physicians. 13As the populations of nonmajority groups continue to grow in the US, efforts that address diversity and retention in the health care workforce become increasingly important.[16][17] Allyship is the continual process in which people with power and privilege work to develop a culture in which disadvantaged groups feel supported and valued. 18There are few existing curricula that train medical residents to support their colleagues and patients specifically through the lens of allyship and privilege. 14,15,19Most existing curricula primarily feature didactic models of teaching; few are activity based; none focus on skill building.One recent publication highlights the need for workshops aimed at clinical allyship skill building to better enable residents to develop as allies to support their peers and their patients. 19In our own needs assessment survey (presurvey), participants expressed that they wanted to engage in small-group discussions to learn about actionable changes, uncover biases, and build skills to develop as allies. 20sed on these key observations, we created this allyship workshop as one part of a four-part DEI curriculum for surgery and anesthesia resident physicians at the University of California, San Francisco (UCSF). 20This 2-hour virtual workshop can be used as a stand-alone session that involves large-group didactics and a number of small-group interactive, reflective, and skillbuilding exercises relevant to the medical professional.The workshop design references Kimberlé Crenshaw's critical race theory (CRT) and transformative learning to explore the concept of allyship and its deep roots in power and privilege. 21,22The workshop can facilitate the process of becoming an ally by creating space for participants to explore and validate their own and their peers' identities and lived experiences.This active introspection on how those identities can affect the way one interacts with others models allyship.Training a health care workforce to support and advocate for patients and peers at an interpersonal level can culminate in broader positive cultural change across the institution.

Methods
Kern's six step approach to curriculum development was used in the creation of this innovative curriculum to teach perioperative residents about privilege and allyship. 23eds Assessment (Presurvey) We administered a general needs assessment survey (Appendix A) 6-8 weeks prior to the allyship workshop during the DEI curriculum introductory session for first-year anesthesia residents that preceded this curriculum in 2020 and 2021. 20This survey was validated through a pilot with medical students and residents for clarity and relevance. 20We also emailed the survey to all general surgery and anesthesia residents at UCSF to reach a wider audience.The survey captured participant demographics, as well as what the residents felt was lacking in their education regarding DEI training, and served as a presurvey for the allyship workshop, including knowledge and perception questions about allyship and privilege.
Facilitator Preparation Experienced facilitators were selected across various specialties representing diverse lived experiences and backgrounds.To be experienced meant having taught a similar type of workshop in the past or having participated in multiple DEI trainings.One week before the workshop, facilitators attended a mandatory 1-hour train-the-trainer session introducing the workshop activities and the facilitator guide (Appendix B).Facilitators also received guidance on how to approach difficult topics and conversations that might arise.

Learning Environment
To prepare for the workshop, participants were provided with a learner guide with course objectives and recommended reading (Appendix C).Due to COVID-19, the session was administered through a virtual video meeting platform (Zoom).We set a maximum facilitator to learner ratio of 1:5 to promote vulnerable conversation.
We began the workshop with a brief house agreement to set house rules and expectations for learning and unlearning.Participants and facilitators agreed upon the following: (1) Assume positive intent, (2) listen actively, (3) participate fully and bravely by leaving your comfort zone and entering the growth zone, (4) step up and step back, (5) share your story using "I" statements, and (6) confidentiality.We encouraged participants to keep their videos on in order to maximize interpersonal interaction.

Participants
This workshop was not designed specifically for perioperative trainees.However, the umbrella DEI curriculum originated from the UCSF Department of Anesthesia, so the learners in the workshop incidentally included only perioperative residents.We worked with the respective residency administrators to secure protected didactic time for all anesthesia CA 1 residents and surgery PGY 4 and PGY 5 residents.

Educational Content
Selection of the educational material was guided by the needs assessment; the material was delivered in a combination of didactics and small-group activities.In the process of creating and curating the educational content, we referenced CRT and intersectionality as frameworks to guide conversations in the workshop and to emphasize the importance of how each person's identities can impact their lived experiences. 21We aimed to create a space for participants to engage in these important conversations to make way for transformative learning and development as true allies (Figure 1).The didactics fetaured important vocabulary for engaging in conversations around allyship, including such terms as true allyship, performative allyship, privilege, and power, as well as important topics like what it meant to be an ally, ways allyship could manifest, and the difference between sponsors and mentors (Appendix D).
The interactive activities included Circles of My Multicultural Self, the Privilege Wheel, a preparation exercise, and a reflection exercise. 24,25The Circles of My Multicultural Self and Privilege Wheel activities were adapted from use in other disciplines to accomplish our workshop objectives. 15The preparation and reflection exercises were novel activities.Each small group had a facilitator and five to six participants who stayed together throughout the workshop.After each small-group activity, participants returned to the large group to debrief.A reporter from each small group was self-selected to summarize their respective discussions directed by the exercises in the facilitator guide (Appendix B).
The Circles of My Multicultural Self activity highlighted the various identities that different individuals might hold and challenged the stereotypes that could be associated with the ways people distinguish themselves.The adapted Privilege Wheel exercise aimed to illuminate the diversity of shared and unique identities present and to foster empathy by learning about one another's lived experiences. 15The reflection exercise was a real-time anonymous Qualtrics survey with questions challenginig the participant to identify actions they could practice that would demonstrate allyship (Appendix E).The preparation exercise was a novel skill-building activity created by one of our facilitators in which participants observed and practiced an effective strategy for approaching the topic of inequity and discrimination in a smallgroup setting.

Postsurvey Assessment and Evaluation
We used the Kirkpatrick model as the framework for curriculum evaluation and a mixed-methods analysis to capture both the impact of the workshop and self-reflective exercises around privilege and allyship. 26,27The postsurvey included both 5-point Likert-scale and open-ended items to collect demographics, assess learners' satisfaction with the workshop and facilitators, and evaluate perception change and participants' understanding around the concepts of allyship. 28The postsurvey (Appendix F) was administered to participants in the last 5 minutes of the workshop.Participants also submitted anonymous self-reflections, as stated above (Appendix E).Responses to both surveys and the reflective exercises were collected using Qualtrics.

Data Analysis
Quantitative analysis included t tests of the pre-and postsurveys using SPSS (IBM).Anonymous identifiers were self-generated by the participants for matching in pre/post analysis.Qualitative data analysis included a content analysis research methodology with consensus coding to analyze the data.Two researchers performed initial coding separately based on frequency of a concept or implied concept using Microsoft Excel. 29They next came together to identify overlapping codes and share reasoning for coding inconsistencies in order to eventually reach consensus.One of the researchers then revisited the final codes to draw conclusions and findings based on the codes that had been identified.

Workshop and Facilitator Satisfaction
Postsurvey responses regarding satisfaction with the workshop and nine facilitators were overwhelmingly positive.On the 5-point Likert-scale (1 = strongly disagree, 5 = strongly agree), the 55 participants evaluated the statements "This allyship workshop is important to my training" with a mean of 4.6 (SD = 0.8), "I believe this allyship workshop is relevant to my workplace" with a mean of 4.7 (SD = 0.8), and "I would recommend this allyship workshop to my peers" with a mean of 4.6 (SD = 0.8; Table 1).
Regarding facilitator satisfaction, participants agreed that the facilitators "were well prepared" with a mean of 4.8 (SD = 0.6), "created a welcoming and inclusive environment for discussions" with a mean of 4.8 (SD = 0.6), and "effectively communicated this information" with a mean of 4.8 (SD = 0.6; Table 1).
Self-Perceived Competence Self-competence was assessed through three statements in the 2021 workshops, which consisted of 30 participants.The mean response to the statement "I know how to define the term allyship" increased from 3.7 (SD = 1.1) to 4.5 (SD = 0.5) from the pre-to postsurvey (p < .05).The mean response to "As an ally, I am likely to mentor individuals who belong to a marginalized group and recommend them for other academic projects" increased from 3.8 (SD = 1.1) to 4.5 (SD = 0.6) from the pre-to postsurvey (p < .05).There was no significant change in the mean response to "I recognize the privilege that I have" from the pre-to postsurvey (Figure 2).

Self-Reflective Exercise
Twenty-five participants submitted self-reflections on the question "What actions can we take in sponsoring or mentoring that mirror the concept of allyship?",summarized by the following themes in the order of prominence: advocating for others (44%), actively seeking out mentorship and sponsorship opportunities (40%), fostering a supportive community (32%), respecting others' identities and experiences (16%), positive role modeling (12%), and acknowledging and leveraging one's own privilege (8%).The The facilitators effectively communicated this information.2% 0% 0% 11% 87% 12 responses to the question "What did you learn about yourself [through this workshop]?"included the intersectionality of one's own identities (75%) and that one was privileged in ways one did not realize (50%).Moving forward, participants ( 14) stated that they would become more self-aware of their privilege (50%), be an ally (43%), speak up and speak out (29%), and practice active listening (21%; Table 2).

Workshop Feedback
At the end of the postsurvey, participants were asked to provide feedback about the workshop.The 31 responses to the question "What did you like most about this workshop?"can be summarized by the following themes: small-group exercises (42%), safe space for open conversation and discussion (39%), effective and well-prepared facilitators (16%), reflecting on one's own identities and privilege (16%), learning from those with different backgrounds (16%), and specific actions and ways to be an ally (10%).The 20 responses to the question "What could be improved in this workshop?"included more time in small groups (55%), less lecture time (20%), encouraging more participation (15%), and more tips for being an ally (10%; Table 2).

Discussion
We developed this novel interactive allyship workshop to create space for participants to self-reflect on their identities and privilege and to facilitate the skill building necessary to help trainees develop as allies.The postsurvey results were overwhelmingly positive.The high satisfaction rate with facilitators indicated their effectiveness despite the limitations of the virtual format due to the COVID-19 pandemic.The results demonstrated that the exercises implemented were useful in encouraging participants to discuss and reflect on their own and their peers' identities.The self-reflection activity also received a unanimously positive response indicating high motivation among participants to apply the allyship training to create a more supportive and inclusive community.The critical thinking and self-reflection employed throughout the workshop represent key steps towards developing as allies within Mezirow's transformational learning framework (Figure 1). 30Our positive findings could help bridge our long-term goal of behavioral change to building a health care workforce of allies who uplift their disadvantaged colleagues and peers.
Through the curriculum feedback, we learned important lessons for future iterations of the workshop.We intend to limit the amount of didactics and allot more time for working together in the intimate, brave spaces of our smaller breakout groups, which focus on engaging in the exercises and discussions.Next, the implementation of an allyship workshop can be challenging due to the difficulty of creating a vulnerable and brave space that empowers participants to share their thoughts and perspectives.We found that facilitators who opened up and shared their own vulnerable experiences first set the tone for the type of discussion that the group would have.As a result, future facilitators will be encouraged to be vulnerable with their learners to help build space for learning and growth.
We delivered the workshop in a virtual format due to the COVID-19 pandemic, which posed another challenge to creating a vulnerable environment in which to learn compared to an inperson workshop.We were concerned that the workshop's interactivity would be heavily impacted by the virtual format but instead discovered that learners were engaged and ready to participate.Experienced facilitators and effective preparatory session materials were likely strong contributors to the highly interactive experience.Furthermore, the virtual format permitted greater flexibility to recruit a more diverse, multidisciplinary group of facilitators and to manage participants' time and location constraints.One could still administer this workshop in an inperson format.We had initially intended to deliver it in person prior to the pandemic.The main adjustment for the virtual format was the emphasis on encouraging participants to keep their videos on during the house rules.
The workshop has several limitations.It is not longitudinal, and thus, our short-term assessments are not reliable measurements of the long-term change we want to achieve (Figure 1).We intend to administer a climate survey as a long-term follow-up to assess the longitudinal retention of allyship knowledge and its transition into behavioral change.Furthermore, technical challenges in the survey launch resulted in the omission of questions assessing self-competency from the 2020 postsurvey; this was corrected in the 2021 survey.Despite the survey having been piloted, several questions remained unclear when survey was actually implemented; we therefore omitted these questions from the final results.Survey responses were voluntary, and so, certain items on the survey received a smaller number of responses than others despite the overall high response rate.There were also significantly more anesthesia participants relative to surgery residents, which highlights the importance of having departmental support to navigate challenging trainee schedules.
To foster a more inclusive work environment in academic medicine, a greater emphasis on retention of a diverse workforce must take priority.Our workshop directly addresses this prevalent issue by creating space for participants to self-reflect and build the skills necessary to develop as allies.The workshop also empowers learners to become advocates as mentors and sponsors, which can help pave a road to increasing marginalized representation through recruitment and retention at all levels of training.We recommend continued evolution and dissemination of this workshop so that allyship training becomes standard within academic medicine to promote institutional change that truly emphasizes a culture of DEI and justice.

Figure 1 .
Figure 1.The transformational learning framework.This conceptual framework shows that transformative learning in the allyship workshop is an ongoing process facilitated by knowledge acquisition, well-prepared facilitators, interactive activities and skill building, and self-reflection, with the ultimate goal of long-term behavioral change.